Sise is a walking encyclopedia of trauma medicine. A New York native, Sise, 50, resembles actor Chazz Palminteri in looks and manner. He stares at you with penetrating intensity, and nothing seems to ruffle him. “I started working here in ’87 part-time and full-time in ’92. Before that I was the chief of vascular surgery at the Naval Hospital. If it’s tough to be in health care, being in one of the highest-performing services of health care makes that toughness especially compelling.” An experienced trauma surgeon, Sise was chief surgeon aboard the USS Guam and USS Iwo Jima during the Persian Gulf War. At Mercy, he works 24-hour shifts with a trauma team that is on call and ready for whatever comes through the door.

Sise explains the distinctions between emergency and trauma medicine. “The emergency department and the trauma center obviously have to work closely together, and the emergency department is an integral part of providing trauma care. But the way it works is, you’re identified as a trauma patient at the scene, either because of the severity of your injury or because of certain criteria. A trauma is not just an injury, but the possibility of an injury or an injury that happens to someone with a pre-existing condition that could make that small injury worse. And ‘injury’ by itself is not enough to qualify as a trauma. A trauma is any major injury or risk of injury that requires immediate diagnostic workup and prompt treatment by qualified professionals.

“For instance, if you’re in an automobile accident where someone is killed, everybody in the car is made a trauma patient because of the likelihood of severe injuries — if one person was killed, there was probably enough force that you were severely injured, even though you may seem stable. If you fall 14 feet or more, if you are involved in a high-speed motor-vehicle accident unrestrained, if you have any number of injuries, the paramedics at the scene will communicate with the base station — and there are a number of base stations around the community based out of hospitals. The base station is where a specially trained doctor and nurse from the emergency department are available to communicate with the paramedics as to whether it’s a medical emergency or a trauma emergency or pediatric or obstetric emergency. They communicate back and forth and they decide, the paramedics and the nurse — the mobile intensive care nurse — whether or not you meet trauma-center criteria.

“So if you’re shot through the chest at the doorstep of Grossmont Hospital, you’ll still go to Sharp, because you’re a trauma patient and we know that at Sharp there is a fully trained surgeon, an operating room, an anesthesiologist, an O.R. nurse — all sorts of people immediately available that aren’t necessarily available at Grossmont on a reliable basis. Now, Grossmont’s a great hospital, but they’re not part of the trauma system, and we’ve proven time and again something we learned in Vietnam, where we flew people to the doctors — that to take the extra 10 to sometimes 20 minutes to fly somebody to the right place is much better for that patient than to take them to the closest facility if they don’t have those resources. So it’s not the geographic location but the resources that make the difference. Then, once you’re a trauma patient, bingo! It sets off the system.”

A string of preventable deaths led to the creation of San Diego’s trauma-care system. “It was organized in 1984. In the 1970s and early ’80s, we did not have a trauma system, so if you were injured, you were taken to the nearest hospital, regardless of its capabilities. There were a couple of very high profile cases where injured patients were taken to hospitals that were the nearest hospitals but weren’t capable of providing trauma care — and they died. It got to a point where in 1982 the county medical society and the Hospital Council, in conjunction with the Department of Emergency Medical Services, commissioned a study in the county by a group called the Amherst Group — a health-care consulting group — and they looked at all the patients who had died in ’82 from trauma and they found that 20 percent of them died a potentially or outright preventable death. So one in five patients who died after trauma could have been saved if they’d had access to an organized trauma system. After that report was received in 1983, we organized a trauma system that came on-line by 1984.

“The way the trauma system works is, the county is the agency that designates whether or not a hospital is a trauma center and can receive trauma patients. There’s a code of law called Title 22, which is part of the California Health and Safety Code that tells you what you have to have. And the American College of Surgeons has published this document that we have to live by. The reason I’m telling you this is that it’s almost schizophrenic. If you are admitted to this hospital or any of the trauma centers, you are tracked and everything that happens to you is timed, recorded, and audited in a way where it’s audited nowhere else in health care — throughout the United States or even the world. Not only are we required to do this by the county, but also by the American College of Surgeons to meet the national standard of what it is to be a trauma center.

“Anyway, in 1984, six trauma centers came on-line: Mercy, ucsd, at the time Grossmont, Scripps La Jolla, and Sharp Memorial, and Children’s for pediatric trauma. Within a year, Grossmont dropped out and Palomar came on-line. Since 1985, those six trauma hospitals have stayed in the system, which is remarkable. At the same time, in L.A. County, in a 40-hospital trauma system, only 13 hospitals are left. This has left a tremendous burden on the other hospitals, particularly the public hospitals.”